Pictures of the Week

IPSIS: Formerly the Spine Intervention Society
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Coming in for a second opinion.
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lobelsteve said:
Did some asshat try and put the wire in at C3-4? At least it is behind the cord.
Click to expand...

C4-5, but yes. She's had 8 revisions so far. Half the contacts are outside of the central canal. I'm trying to convince myself that it's some weird paddle that I have never seen before because I have trouble believing it otherwise.

I guess the benefit of accessing that level is that if you screw it up it's a quick kill.
 
No doubt. Just pull that out. I don’t understand how she has had 8 revisions. Is this for “crps” and she is sabotaging each implant? She had a perfect c spine from the image posted.
 
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Story just gets weirder and more fraudulent. The CT myelogram was apparently before her most recent revision. The attached picture is the most recent. Apparently she's had 8 revisions for things like lead migration, leads disconnecting at the battery site and every time he took out the whole thing and replaced it. Eight IPGs. Unbelievable. Her initial indication for the surgery was cervical radiculopathy -- not surprised a peripherally placed paddle isn't doing much.

Any reason I can't take this paddle out? It's just floating out in soft tissue so it looks like it would be pretty simple to just cut it out. Am I missing something?
 
What in the hell?

Taking that paddle out shouldn't be difficult. That sagittal looks unimpressive to me.

You need the paddle op note though. See what's tied down and where. I'd not assume that SCS is done in any way that would be considered normal and there's no telling where there's stitch or what.
 
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Baron Samedi said:
Any reason I can't take this paddle out? It's just floating out in soft tissue so it looks like it would be pretty simple to just cut it out. Am I missing something?
Click to expand...

Agreed. I would look at the OP note for sure. It looks easy to remove. These things are sometimes sutured down to dura or other structures, and rarely with lami defects you can develop a hygroma, but that is most likely their attempt at field stimulation with a paddle lead. You could also verify with a repeat CT myelogram prior to any surgical events.
 
older practice.JPG


Not saying my schedule is lighter at end of year. But it is older. How would you like to be 80 and told you are not in the top 5 oldest patients today.
 
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lobelsteve said:
Shoot to kill the surgeon. (figuratively- med mal and insurance fraud). Medical board, atty.
Click to expand...

I already filed an insurance fraud and abuse complaint. Good idea to reach out to the medical board.

edit: Stupid state doesn't have anonymous reporting. I think I'll stick to the insurance angle and see where I get.
edit: edit: screw it, I complained.
 
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Wet = Modic IMO
Unless it's Slippery When Wet like Bon Jovi.
 
Baron Samedi said:
But modic changes refer to the endplate, not the disc, right? This radiologist also referred to the L2-3 modic changes as endplate changes, not a wet disc.
Click to expand...

Wet = Toad the Wet Sprocket...Walk on the ocean...
 
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lobelsteve said:
View attachment 288427




Help me out folks, What is a "wet" disk?
Click to expand...

"wet" implies a soft disc herniation, or a "newer" herniation, i think. hard disc herniations are typically older. i think the wetness is supposed to be the nucleus pulposus.

but it is a stupid adjective to use
 
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Do plain films show those vertebrae looking like that? So odd. It’s like you live on another planet with all the findings your people seem to have.
 
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lobelsteve said:
Moving on.

Funny bones C6-T3. No symptoms of radic or myelopathy. Seen for back pain and someone got neck MRI anyways.View attachment 288440
Click to expand...

is that midline saggital?

agree with the alien comment

looks like some sort of developmental dysplasia. associated with any weird syndrome or scoliosis?
 
lobelsteve said:
Spoke with Rads. No syndrome.
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Does the patient have a history of vascular or pulmonary issues? The AP diameter develops as a function of pressure and blood flow I think? It looks as if there's some sort of intrathoracic pressure issue going on.
 
This AM I come in and open my folder that contains Rx things I need to sign, PT orders, that type of stuff...Lo and behold I have a new journal awaiting me, and one I did NOT sign up for! PhD Editor in Chief who either wrote or co-wrote a lot of the articles himself. Peruse if you will these amazing articles and notice this is NOT a submission of research to a journal for publication; it is surveillance for articles that are favorable to this POS publication.

This is the type of BS that results in my having to do my 2 minute "thing" about CBD and THC for people whose friends have been telling them to ask me about Rx'ing them "CDB marijuana" or "DCD pot."
 

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Metastatic lung CA. Initially treated as infection until biopsy.
lung CA.jpg
 
She has pain.
 

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Young guy. Axial extension-based pain with bilateral L5 pseudoarticulations that I suspect are the primary pain generator. I want to inject for diagnostic and therapeutic reasons but unsure where exactly I should target my needle -- thinking the inferolateral corner of each L5 transverse process. Any thoughts?
 
Baron Samedi said:
View attachment 292129

Young guy. Axial extension-based pain with bilateral L5 pseudoarticulations that I suspect are the primary pain generator. I want to inject for diagnostic and therapeutic reasons but unsure where exactly I should target my needle -- thinking the inferolateral corner of each L5 transverse process. Any thoughts?
Click to expand...

put a lot of tilt in there to uncover the bertolatti joint by getting the iliac crest out of the way. you may not get a great pseudoarthrogram, though. inject the SIJ when (if) your shot doesnt work
 
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Perhaps not relevant to your issue, but are you certain that is L5 and not S1?


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NJPAIN said:
Perhaps not relevant to your issue, but are you certain that is L5 and not S1?


Sent from my iPhone using Tapatalk
Click to expand...

Excellent point to discuss. Had an L3 kypho yesterday. Rads read it as L4 and 6 lumbar vertebrae.
There are several conventions on naming lumbar vertebrae.
1.Iliac crest is L4
2. Aorta splits at L4
3. Lowest vertebrae over a fully formed disc is L5.
4. First vertebrae without ribs is L1.
5. Count from C1 (when available).

All are correct as long as the treatment is done at the level intended to treat. But can be devastating when a Radiologist and a surgeon (pain doc) are using different naming conventions and the wrong level gets treated.
 
lobelsteve said:
Excellent point to discuss. Had an L3 kypho yesterday. Rads read it as L4 and 6 lumbar vertebrae.
There are several conventions on naming lumbar vertebrae.
1.Iliac crest is L4
2. Aorta splits at L4
3. Lowest vertebrae over a fully formed disc is L5.
4. First vertebrae without ribs is L1.
5. Count from C1 (when available).

All are correct as long as the treatment is done at the level intended to treat. But can be devastating when a Radiologist and a surgeon (pain doc) are using different naming conventions and the wrong level gets treated.
Click to expand...
Good points.

I find it most helpful to just discuss level in relation to the transitional lumbosacral segment and most caudal fully formed disc. Regardless of whether one calls it L4/5/s1. Eliminates ambiguity.
 
I discussed this with Tim Maus from Mayo Radiology a few years ago. He said if there is any ambiguity that you must count down from T1 as T1 is always T1. Anything else is subject to variability. Hypoplastic thoracic ribs, lumbar ribs, sacralization, lumbarization.


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NJPAIN said:
I discussed this with Tim Maus from Mayo Radiology a few years ago. He said if there is any ambiguity that you must count down from T1 as T1 is always T1. Anything else is subject to variability. Hypoplastic thoracic ribs, lumbar ribs, sacralization, lumbarization.


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Click to expand...
True, however thoracic imaging not always available.

Therefore my failsafe is comparing the lumbar Xray to mri, particularly the lateral view.
 
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